Treating frailty for what it is — a medical condition

Senior woman's hands on walker

David Sacks, Taxi photo via Getty Images

David Sacks, Taxi photo via Getty Images

Marlene CimonsWashington Post

As a medical resident 30 years ago, Ava Kaufman remembers puzzling over some of the elderly patients who came to the primary-care practice at George Washington University Hospital. They weren't really ill, at least not with any identifiable diseases. But they weren't well, either.

They were thin and weak. They had no energy. They tired easily. Their walking speed was agonizingly slow. "We couldn't put our finger on a specific diagnosis or problem,'' Kaufman says. "We didn't have a word for it then.''

Today we do. It's called frailty. There have always been frail people, but only in recent years has the term "frailty" become a medical diagnosis, defined by specific symptoms and increasingly focused on by those who deal with the medical issues of the elderly. Clinicians now are looking at ways to prevent or delay frailty, sometimes even reverse it.

"Frailty is not an age, it's a condition," says Kaufman, a Bethesda, Md., internist and geriatrician. "We know it when we see it, and it's always been with us."

While frailty is most often associated with the elderly, some old people never get frail. Experts now regard it as a medical syndrome, that is, a group of symptoms that collectively characterizes a disease, one that probably has biological and genetic underpinnings and can afflict even those in middle age if they have some other debilitating chronic disease. Frail people usually suffer from three or more of five symptoms that often travel together. These include unintentional weight loss (10 or more pounds within the past year), muscle loss, a feeling of fatigue, slow walking speed and low levels of physical activity.

"The symptoms are causally linked together in a vicious cycle,'' says Linda P. Fried, an internist who is dean of the Columbia University Mailman School of Public Health. In 2001, Fried and research colleagues were the first to define the physical characteristics of frailty in a landmark paper published in the Journal of Gerontology. "These are people at risk of very bad outcomes."

The signs of frailty can be obvious, even to the layperson. The frail often look "as if a puff of wind could blow them over," Fried says. Their gait is slow and unsteady. Over the years, they seem to shrink in size, the result of muscle wasting that occurs naturally as people age. Everyone loses muscle mass as they approach their 90s, although studies have shown that resistance training — weightlifting — can slow this process.

Because it typically worsens over time, frailty often leads to more serious consequences, such as a disabling fall, even death. Frail people are, in fact, at higher risk of falls, and have a much more difficult time recovering if they become ill or enter the hospital. "Putting a frail person in the hospital often is the beginning of the end,'' Kaufman says.

How to stay healthy longer

To be sure, many older Americans continue to lead active and productive lives. However, the nation's increasing longevity is bringing new challenges for health and social programs. Americans' life span in 2009 was 78.5 years, according to the Centers for Disease Control and Prevention, about three decades more life than in 1900, when the average was 47.3 years.

"We've added 30 years to the human life span, which is an unparalleled success story for public health, medicine and education,'' Fried says. "As a result, it is critically important that we help these people who are living longer stay healthy.''

Of those living alone or with families, not in nursing homes or hospitals, about 4 percent of men and 7 percent of women older than 65 were frail, according to the parameters used by Fried and her colleagues in the 2001 study. The researchers, who studied more than 5,000 adults 65 and older, also found that the chances of frailty rose sharply after age 85, to about 25 percent. These numbers, the most recent data available, reflected conditions prior to 2001, leaving "an important but unanswered question as to whether the frequency of frailty is the same, increasing or decreasing" today, Fried said.

Also, women are more likely than men to be frail, possibly because women typically outlive men and "start out with less muscle mass than men and, once they lose it, they may cross the frailty threshold more rapidly than men,'' Fried says.

Stephanie Studenski, principal investigator at the Claude D. Pepper Older Americans Independence Center at the University of Pittsburgh, has been practicing in the geriatrics field for 30 years and sees "older people across the full spectrum, from frail 60-year-olds to vigorous 95-year-olds,'' she says. For the younger group, who usually are frail because of multiple chronic conditions, "sometimes medications can worsen frailty with their side effects, so adjustments can help,'' she says. "I tell these patients I can often make you better, give you more reserve and increase your resilience although not totally cure you. We can't change from black to white, but often can push the black into gray.''

For those in their 80s or older, however, the causes of frailty are sometimes less obvious.

Barbara Resnick, a geriatric nurse practitioner in Baltimore, remembers an 85-year-old woman, living at home, who "stopped going out to dinner with friends; she would say she was too tired and didn't have the energy. She wasn't walking out to get her mail anymore. She was eating less and losing weight rapidly."

Her adult daughter became concerned and brought her mother to Resnick "and asked us to fix the problem," recalls Resnick, who chairs the board of the American Geriatrics Society.

But there often is no quick fix. Clinicians checked the woman for underlying disease — they found none — and adjusted her medications. They also urged the woman to increase her physical activity, Resnick says. "That's really the best way to manage frailty: Engage as much as you can; optimize what you can do. What's important is resilience.''

The woman is doing better today. "She is still plugging along," Resnick says. "We actually stopped her meds, except for critical ones, and she did gain some weight. She's not really deeply engaged, but is surviving."

Similarly, Kaufman recalls "a wonderful gentleman'' in his 80s who had been doing quite well until his wife fell, broke her hip and had to enter a nursing home. The couple had been married 60 years. After she left, he began to slow down physically, and he stopped eating.

"He just gave up,'' Kaufman says. "There was no one specific thing. But within a few months, he died. What do you put on a death certificate? If it was a pediatric case, we'd say 'failure to thrive.' He died of frailty.''

An inflammatory problem?

Jeremy D. Walston, a geriatrician and molecular biologist who co-directs the Biology of Healthy Aging Program at Johns Hopkins University School of Medicine, believes that frailty may in part be related to the body's inability to regulate its normal inflammatory response. His research has found that frail people suffer from a constant low-grade inflammatory state.

"When something attacks the body, it sends out a number of inflammatory signals to fight an infection or heal a wound,'' says Walston, who also is principal investigator for Hopkins' Older Americans Independence Center. "In frailty, these pathways get turned on, and they don't get turned off." Such chronic inflammation can lead to weakening of skeletal muscles and the immune system.

Frail people also are less able to process glucose properly, he says, and they secrete more cortisol, a hormone that over time, as with chronic inflammation, also can damage skeletal muscles and the immune system.

Scientists don't yet understand how these findings relate to the more predictable changes associated with aging, or whether they are a cause — or a consequence — of frailty.

Researchers also are studying the impact of moderate physical exercise in preventing the most powerful indicator of frailty: slow walking speed. An ongoing study of 1,600 people between the ages of 70 and 89 is comparing the effects of a moderate-intensity walking and weightlifting to a program of health education only. The exercise group walks for 30 minutes several times a week and uses ankle weights to improve lower body strength. The education group receives information on diet, managing medications and other health-related matters, but not about physical exercise.

A smaller, earlier phase of the study suggested that physical activity was key, with a 26 percent reduction in walking problems among those who worked out regularly.

"You don't have to go to an exercise program at the gym,'' Kaufman says. "Clean your house. Walk to the mailbox to get your mail, or work in your garden. The greatest common denominator of frailty is muscle loss and slowing of gait, and it's amazing what physical exercise can do.''

Walston agrees. "Growing old may be inevitable, but growing frail is not,'' he says.

Cimons is a former Washington-based health policy reporter for the Los Angeles Times.